PSYCHOPHARMACOLOGY

BIO 301
 Introduction
• 1st introduced in the 1950s
• Revolutionized changes in managing psychotic
illness
• 1st psychiatric medication developed
___________; it did for psychiatry what PCN
did for medicine.
 Antipsychotic Medications
• AKA ______________ or ______________
• Mainstay of tx for schizophrenia and other
psychotic disorders.
• 2 categories
– First generation (FGA) [conventional] or
___________ antipsychotics
– Second generation (SGA) [________________]
– Differ in mode of action, side effects & potency as
compared to the typical antipsychotics
 Antipsychotic Medications
• First Generation [FGAs]
– Block receptors for dopamine in the CNS
– Cause more serious movement disorders
[EPS-extrapyramidal symptoms]
– Classified as low, medium or high potency
– Potency refers to the size of the dose
needed to elicit a given response
 Antipsychotic Medications
• Second generation
– Moderate blockade or receptors for
dopamine & much stronger blockade of
receptors for serotonin.
– Produce lower potential for EPS effects &
greater efficacy in negative symptoms,
cognitive symptoms & refractory illness.
– Risk of metabolic effects
Antipsychotic Medications Indications
• Treatment of psychosis which includes:
– Schizophrenia, schizoaffective disorders &
delusional disorders.
– Patient with psychosis from secondary
causes benefit from short-term
antipsychotic medications while the
underlying illness is being treated
 Goals of Antipsychotic Therapy
• Typical [FGA]: effective in reducing or alleviating
the _______________symptoms.
• Atypical [SGA]: more effective in alleviating
____________________symptoms & other
symptoms related to psychosis.
• Return the client to normal daily functional &
provision of self-care
• Minimize side effects [use optimal dose w/least
possible side effect].
• Help client manage side effects so that they will
remain complaint with medication regimen
 Adverse Effects of Antipsycotics
• High potency, conventional, FGA
[Typical]poses higher risk for
______[__________________________].
– _________________________
– _________________________
– _________________________
– _________________________
 Dystonia
• Spasms of the neck [Torticollis]
• Spasms of the back [Retrocollis]
• Spasms of the tongue [Glossospasm]
• Dystonic reactions usually occur during the early
stages of treatment
• Common post IM injections of antipsychotics
• Risk factors include administration of high
potency agency, large doses & parenteral
injections
• Considered a MEDICAL EMERGENCY
• Anticholinergic: benztropine [Cogentin] IM, IV
 Pseudoparkinsonism
• Characterized by symptoms that include:
– Decrease movements [bradykinesia, akinesia]
– Muscle rigidity [cog-wheeling, lead pipes
– Resting tremor
– Drooling
– Mask-like face
– Stoop position
– Shuffling gait
– Treatment: reducing medication or a change
to an antipsychotic w/less potential for EPS
– Anticholinergic: benzytropine [Cogentin],
diphenhydramine [Benadryl]
 Akathisia
• Characterized by the following symptoms:
– Motor restlessness
– Pacing
– Squirming
– Rocking
– Inability to sit still
• Symptoms are dose related
• Improves w/decreasing the dose or change to
low potency agent
• Beta-blockers, Benzodiazepines, anticholinergics
 Oculogyric Crisis
• Involuntary upward deviation of the eyes
• Spasms of eyeball
• May occur in one eye or both
• Do NOT confuse with seizure: NOT a seizure
• Considered MEDICAL EMERGENCY
 Medication for EPS
• Anticholinergic
– Benztropine [Cogentin]
– Trihexyphenidyl [Artane]
• Antihistamine
– Diphenhydramine [Benadryl]
• Dopamine antagonist
– Amatadine [Symmetrel]
 Tardive Dyskinesia
• Involuntary choreoathetoid
• Symptoms include
– Abnormal movements of voluntary muscle groups
after a prolonged period
– Commonly affected muscles:
– Face
– Mouth, tongue
– Finger
– Grimacing, lip smacking, tongue poking/pling,
writhing movements of fingers, toes [pill rolling]
 Tardive Dyskinesia
• Risk factors include
– Longer lengths of time of antipsychotic use
– High doses
– High potency drugs
– Use of typical [conventional] FGA
– No treatment for TD
– Atypical have much lesser risk than FGA
– Symptoms caught early, patient may have a
chance that TD will resolve
 Drowsiness
• Most common: first days of treatment
• Disappears in 1-2 weeks usually
• Sedation: significant w/low potency, FGA:
chlorpromazine [Thorazine] & thioridazine
[Mellaril]: Phenothiazine’s
• Avoid ETOH, antihistamines, sleeping aid
• Take daily dose at hs to avoid this side effect
• Warn against handling hazardous machinery,
activities.
 Anticholinergic Side Effects
• Side effects present as:
• ______________________
• ______________________
• ______________________
• Nasal congestion
• Ejaculatory inhibition
• Most annoying but NOT serious
 Cardiovascular Side Effects
• Symptoms manifest as
–Postural hypotension: dizziness
–Arrhythmias, palpitations [Geodon]
–Changes in QT intervals, ziprasidone
[Geodon]: Benzisoxazoles
–Fatal FGA dysrhythmias
• ____________, _____________,
_______________
 Neuroleptic Malignant Syndrome
• MEDICAL EMERGENCY
• Symptoms present as:
– Decreased, acute change in mental status
– Severe increase muscle tone [rigidity] “Lead
pipe”
– Hyperpyrexia, labile hypertension,
tachycardia, tachypnea, diaphoresis,
drooling, renal failure
 NMS
• Risk factors
– Past hx NMS
– Poly-psychotropic meds
– Rapid close titration
– Use high potency antipsychotics in high doses
– Young men are more at risk
– Labs include: Elevated creatinine phosphokinase
levels
 Treatment for NMS
• IMMEDIATE discontinuation: antipsychotic
• Hydration w/fluids
• Administer acetaminophen, cooling blankets
for hypothermia
• Management of arrhythmias
• IV dantrolene [direct-acting muscle relaxant]
• Administering anticholinergic medications
 Weight Gain
• Clozapine [Clozaril] and olanzapine [Zyprexia]
have higher weight gain potential
• Must monitor blood glucose levels
• Screen for adult onset diabetes Type II
• Excessive weight gain may cause a switch to a
different antipsychotic
• Increase in cholesterol and triglycerides
 Photosensitivity
• A general term used to describe either the
common phototoxic response or the uncommon
photoallergenic reaction
• Symptomatic present as:
– Sunburn
– Pruritis
– Vesicular eruptions
– Eczematous dermatitis
• Treatment includes topical burn cream,
antihistamines, steroids indicated for
photoallergence reactions
 Dermatologic Changes
• Poikilothermia
– Inability to regulate body temperature with
environment temperature
• Neuroendocrine defedts:
– Galactorrhea and Gynecomastia
• Due to elevation of prolactin levels
 Other
• Seizure
– FGA: reduce seizure threshold
– Seizure precautions should be implemented
• Sexual dysfunction
– Suppression of libido: women
– Erectile dysfunction: men
– Decrease dose or switch to HP FGA
 Clinical Use Dosage
• Administered in divided doses
• To minimize side effects
• Determine the patient’s ability to tolerate the
medications
• Dosage regimen is usually simplified to a once
a day dose [improves compliance]
• Do not need to monitor serum levels
Examples of Typical Antipsychotics
• Chlorpromazine [Thorazine]: prototype
phenothiazine
• Fluphenazine [Prolixin]
• Pherphenazine [Trilafon]
• Thioridazine [Mellaril]
• Trifluoperazine [Stelazine]
• Haloperidol [Haldol]
• Thiothixine [Navane]
• Loxapine [Loxitane]
 Decanoate
• Prolixin [fluphenazine decanoate]
• Haldo [haloperidol decanoate]
• Long-acting Risperidone [risperdal]
[Respiridone microspheres]
• Used to improve compliance for patients who
have difficulty following a PO regimen
• Usually administered every 2 weeks
• Given IM
 Atpical Antipyschotics
Clozaril [Clozapine]
• Clozaril [clozapine]: prototype
• Blocks receptors for dopamine & serotonin; blocks
dopamine 2
• Used for refractory illness
• Titrated slowly to avoid side effects [sedation,
orthostatic hypotension, DROOLING
• Must monitor WBCs as the medication causes
AGRANULOCYTOSIS
• Patient’s at risk for agranulocytosis are those who are
immunocompromised
• Potential metabolic effects
 Clozaril Side Effects
• Sedation: common
• AGRANULOCYTOSIS
• Anticholinergic side effects
• EPS: common
• NMS: patient is at risk
• CV: tachycardia, orthostatic [initial dose]
• Weight gain: common
• Hypersalivation: COMMON
• Seizure: dose related
– General tonic-clonic
 Atypical Antipyschotics
Risperidone [Risperidol]
• Effective in treating [+] and [-] s/s of
schizophrenia
• Side effects include
– EPS: low incidence
– TD: less than typical antipyschotics
– CB: hypotension
– Weight gain: not significant
– Hyperprolactinemia
 Olanzapine [Zyprexa]
• Effective in treating [+] and [-] symptoms of
schizophrenia psychosis associated w/bipolar
disorder
• Side effects
– Sedation/anticholinergic: common
– Seizure: to avoid do not give with clomipramine
– Hyperprolactinemia: high
– Weight gain/Type II DM: common
 Quetiapine [Seroquel]
• Side effects
• Sedation: common
• CV: avoid in pt w/hx of CV disease
• Weight gain: not significant
• Cholesteraol/triglyceride elevation: common
 Ziprazidone [Geodon]
• Must take with food
• Side effects
– Prolongation of QT interval and fatal heart arrhythmia
– GI discomfort: nausea, dyspepsia, constipation,
diarrhea, dry mouth
– Drowsiness
– Akathisia
– Dizziness
• EPS
• Dystonia
 Atypical Agents
• Aripirazole[Abilify]
• Clozapine [Clozaril]
• Olanzapine [Zyprexa
• Quetiapine [Seroquel]
• Risperidone [Risperdal]
• Ziprasidone [Geodon]